Cutaneous Lyme Borreliosis: Guideline of the German Dermatology Society

Dermatology OPEN ACCESS Guideline

Cutaneous Lyme borreliosis: Guideline of the German Dermatology Society

Kutane Lyme-Borreliose: Leitlinie der Deutschen Dermatologischen Gesellschaft

Abstract This guideline of the German Dermatology Society primarily focuses on Heidelore Hofmann1 the diagnosis and treatment of cutaneous manifestations of Lyme bor- Volker Fingerle2 reliosis. It has received consensus from 22 German medical societies 3 and 2 German patient organisations. It is the first part of an AWMF Klaus-Peter Hunfeld (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesell- Hans-Iko Huppertz4 schaften e.V.) interdisciplinary guideline: “Lyme Borreliosis – Diagnosis Andreas Krause5 and Treatment, development stage S3”. 6 The guideline is directed at physicians in private practices and clinics Sebastian Rauer who treat Lyme borreliosis. Objectives of this guideline are recommen- Bernhard Ruf7 dations for confirming a clinical diagnosis, recommendations for a stage- Consensus group related laboratory diagnosis (serological detection of IgM and IgG Bor- relia antibodies using the 2-tiered ELISA/immunoblot process, sensible use of molecular diagnostic and culture procedures) and recommenda- 1 Klinik für Dermatologie und tions for the treatment of the localised, early-stage infection (erythema Allergologie der TU München, migrans, erythema chronicum migrans, and borrelial lymphocytoma), München, Germany the disseminated early-stage infection (multiple erythemata migrantia, 2 Bayerisches Landesamt für flu-like symptoms) and treatment of the late-stage infection (acro- Gesundheit und dermatitis chronica atrophicans with and without neurological manifest- Lebensmittelsicherheit (LGL) ations). In addition, an information sheet for patients containing recom- Oberschleißheim, Germany mendations for the prevention of Lyme borreliosis is attached to the 3 Zentralinstitut für guideline. Labormedizin, Mikrobiologie & Krankenhaushygiene, Zusammenfassung Krankenhaus Nordwest, Frankfurt, Germany Diese Leitlinie der Deutschen Dermatologischen Gesellschaft bezieht 4 Professor-Hess-Kinderklinik sich primär auf die Diagnostik und Therapie von kutanen Manifestatio- Klinikum Bremen-Mitte, nen der Lyme-Borreliose. Sie ist Teil 1 der geplanten interdisziplinären Bremen, Germany AWMF Gesamtleitlinie „Lyme-Borreliose – Diagnostik und Therapie 5 Immanuel Krankenhaus Entwicklungsstufe S3“. Berlin, Berlin, Germany Sie wurde interdisziplinär von 22 deutschen Fachgesellschaften und 2 deutschen Patientenorganisationen konsentiert und richtet sich an 6 Neurologische Universitätsklinik, Freiburg, Ärzte in Praxis und Klinik, die mit der Behandlung der Lyme-Borreliose Germany befasst sind. Ziel der Leitlinie ist es, Empfehlungen zur Absicherung der klinischen 7 Klinik für Infektiologie Klinik Diagnosen, Empfehlungen zur stadiengerechten Labordiagnostik (sero- St Georg, Leipzig, Germany logischer Nachweis von IgM- und IgG-Borrelienantikörpern mit dem 2-Stufenverfahren ELISA/Immunoblot sowie der sinnvolle Einsatz mole- kulardiagnostischer und kultureller Verfahren) und Empfehlungen zur Therapie der lokalisierten Frühmanifestationen (Erythema migrans, Erythema chronicum migrans und Borrelienlymphozytom), zur Therapie der disseminierten Frühmanifestationen (Multiple Erythemata migrantia und/oder grippeartige Symptomatik nach Zeckenstich) und zur Therapie der Spätmanifestationen (Acrodermatitis chronica atrophicans mit und ohne neurologische Manifestationen) zu geben. Außerdem werden Empfehlungen für Patienten zur Prävention der Lyme-Borreliose und zur Nachbeobachtung eines Zeckenstiches formuliert.

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Preamble 1 Introduction

This guideline primarily focuses on the diagnosis and The infectious disease most frequently transmitted by treatment of cutaneous manifestations of Lyme borrelio- ticks in Europe is Lyme borreliosis. The Borrelia are sis. It is the first part of the scheduled interdisciplinary transferred to the skin during the blood sucking process guideline: “Lyme Borreliosis – Diagnosis and Treatment, of the hard-bodied tick Ixodes ricinus. There the Borrelia No. 013-080, Development Stage S3”. are either killed off by the (unspecific, innate) immune This part has already received consensus from 22 med- system, or a localised infection occurs which leads to ill- ical societies and 2 patient organisations. The German ness in only a small percentage of those infected. Most Cochrane Centre, Freiburg (Cochrane Germany) is cur- often there is an inflammation of the skin, typically in the rently conducting systematic review and assessment of form of an erythema migrans or, seldom, as borrelial the literature to develop this guideline to stage 3. lymphocytoma. In the course of the infection the Borrelia The interdisciplinary guideline group is currently preparing can disseminate and attack various organs. They part 2 “Neuroborreliosis” which will be followed by part primarily affect the skin, joints and nervous system. Acro- 3 “Lyme Arthritis, Lyme Carditis and Other Rare Manifest- dermatitis chronica atrophicans can develop as a chronic ations”. or late-form of skin manifestation. Synonyms 1.1 Target group

Cutaneous borreliosis, cutaneous manifestations of Lyme This guideline is directed at physicians in private practices borreliosis, skin borreliosis, cutaneous Lyme borreliosis, and clinics who treat Lyme borreliosis. cutaneous Lyme disease 1.2 Objectives of this guideline Search terms • Recommendations for confirming a clinical diagnosis Borrelia burgdorferi infection, hard-bodied tick borreliosis, • Recommendations for a stage-related laboratory dia- Lyme disease, cutaneous Lyme borreliosis, erythema gnosis: serological detection of IgM and IgG Borrelia migrans disease, erythema migrans, erythema chronicum antibodies using the 2-tiered ELISA/immunoblot pro- migrans, lymphadenosis cutis benigna, borrelial lympho- cess; sensible use of molecular-diagnostic and culture cytoma, multiple erythemata migrantia, multiple erythema procedures migrans, acrodermatitis chronica atrophicans. • Treatment of the localised, early-stage infection ICD-10-No: A69.2, L90.4 (erythema migrans, erythema chronicum migrans and AWMF Register No 013-044 borrelial lymphocytoma) • Treatment of the disseminated early-stage infection (multiple erythemata migrantia, flu-like symptoms) List of abbreviations • Treatment of the late-stage infection (acrodermatitis chronica without neurological manifestations) • ACA – Acrodermatitis chronica atrophicans • Treatment of the late-stage infection (acrodermatitis • BL – Borrelial lymphocytoma chronica with neurological manifestations) • EM – Erythema migrans • Prevention of Lyme borreliosis • ECM – Erythema chronicum migrans Recommendations for observing the area around the • i.v. – Intravenous tick bite • BW – Body weight Information sheet for patients (Annex 1 in • LB – Lyme borreliosis Attachment 1) • LTT – Lymphocyte transformation test • MEM – Multiple Erythemata migrantia 1.3 Participating medical societies • MiQ – Quality standards in microbiological-infectiolo- gical diagnostics Steering group • NAT – Nucleic acid amplification techniques • NSAID – Nonsteroidal anti-inflammatory drugs • Responsible: • PCR – Polymerase chain reaction Prof. Dr. med. Heidelore Hofmann – coordinator • p.o. – Per os German Dermatology Society (DDG) • PPI – Proton pump inhibitor • Prof. Dr. med. Sebastian Rauer – coordinator, deputy • RCT – Randomised controlled trial Dr. Stephan Kastenbauer • SNRI – Serotonin-norepinephrine reuptake inhibitor German Society of Neurology (DGN) • Dr. med. Volker Fingerle German Society for Hygiene and Microbiology (DGHM)

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• Prof. Dr. med. Klaus-Peter Hunfeld 1.4 Methods The German United Society of Clinical Chemistry and Laboratory Medicine (DGKL) and INSTAND e.V. This guideline is based on an update of AWMF Guideline • Prof. Dr. med. Hans-Iko Huppertz No. 013-044 “Cutaneous Manifestations of Lyme Borrel- German Society of Paediatrics and Adolescent Medi- iosis”, development stage S1, which was created by a cine (DGKJ) and German Society of Paediatric Infecto- committee of experts in 2009. logy (DGPI) The guideline was created in accordance with the meth- • Prof. Dr. med. Andreas Krause odological requirements of the Association of the Scientif- German Society of Rheumatology (DGRh) ic Medical Societies in Germany (AWMF) for developing • Prof. Dr. med. Bernhard Ruf and further developing diagnosis and treatment German Society of Infectious Diseases (DGI) guidelines. It is an S2k guideline in accordance with the Consensus group AWMF’s three-stage concept. The composition of the guideline group was interdisciplinary (IDA) and the appoint- • Prof. Dr. med. Elisabeth Aberer ed mandate holders of the expert medical societies were Austrian Society of Dermatology and Venerology informed of the scheduled update on 11/2/2014. (ÖGDV) Uniform formulations are used in order to standardise • Prof. Dr. med. Karl Bechter the recommendations of the guideline. The German Association of Psychiatry, Psychotherapy The following gradations shall apply here: and Psychosomatics (DGPPN) • Prof. Dr. med. Michael H. Freitag • Strong recommendation: “shall” German College of General Practitioners and Family • Recommendation: “should” Physicians (DEGAM) • Open recommendation: “may be considered” • PD Dr. med. Gudrun Goßrau • Recommendation against an intervention: “should German Pain Society (DGSS) not” • Prof. Dr. med. Gerd Gross • Strong recommendation against an intervention: Paul Ehrlich Society for Chemotherapy (PEG) “shall not” • Prof. Dr. med. Rainer Müller German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNOKHC) 2 Microbiology of the pathogen • Dr. med. Kurt Müller / PD Dr. med. Walter Berghoff In Europe, 5 human-pathogenic genospecies from the German Borreliosis Society (DBG) Borrelia burgdorferi sensu lato complex have so far been • Prof. Dr. med. Mathias Pauschinger isolated: B. afzelii is the most frequent, followed by German Society of Cardiology and Cardiovascular Re- B. garinii, B. bavariensis, B. burgdorferi sensu stricto and search (DGK) B. spielmanii [1], [2], [3], [4]. • Prof. Dr. med. Monika A. Rieger The human pathogenicity is still unclear for B. valaisiana, German Society for Occupational and Environmental B. lusitaniae and B. bissettii. All of the species that have Medicine (DGAUM) been ascertained to be human-pathogenic are found in • PD Dr. med. Rainer Schäfert Europe. Only B. burgdorferi sensu stricto is present in the German Society of Psychosomatic Medicine and USA, and all of the species are present in Asia except for Medical Psychotherapy (DGPM) and the German Col- B. burgdorferi sensu stricto. The various genospecies of lege of Psychosomatic Medicine (DKPM) the Borrelia burgdorferi sensu lato complex are genetically • Prof. Dr. med. Stephan Thurau very heterogenic [5] and exhibit an organotropism in hu- German Ophthalmological Society (DOG) man infections. Erythema migrans is triggered by all • Prof. Dr. rer. nat. Reinhard Wallich 5 genospecies. Almost only B. afzelii is detected with ac- German Society for Immunology (DGI) rodermatitis chronica atrophicans, B. garinii and B. bav- • Dr. Hendrik Wilking ariensis are often present in neurological manifestations, Robert Koch Institute (RKI) and B. burgdorferi sensu stricto mainly affects the joints Patient supporting groups [6]. B. spielmanii has so far only been isolated from erythema migrans [2], [7]. • Ursula Dahlem Action Alliance Against Tick-Borne Infections Germany (OnLyme-Aktion) • Ute Fischer / Karin Friz Borreliosis and FSME Association Germany (BFBD) Moderation • Prof. Dr. med. Ina B. Kopp AWMF Institute for Medical Knowledge Management

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Figure 1: Seroprevalence of B. burgdorferi antibodies in Germany. KIGGS and DEGS studies [13] 3 Epidemiology Therefore, it can be concluded that the epidemiological data currently available is not sufficient for a definitive Lyme borreliosis mainly exists between the 40th and 60th clarification. Data published up until now in Germany in- parallels of the northern hemisphere in line with the dicates the incidence of Lyme borreliosis to be some- presence of its vectors. Few relevant epidemiological in- where between 60,000 to >200,000 cases per year. vestigations have been conducted in Europe. A popula- In a major nation-wide seroprevalence study of children tion-based study in southern Sweden reveals an incidence (KIGGS) and adults (DEGGS) it was shown that the per- of 69 per 100,000 inhabitants [8]. In a prospective, centage of Borrelia-specific antibodies in serum increases population-based study of the region around Würzburg with increasing age of the population and already has an over a 12 month period, 313 cases of Lyme borreliosis incidence rate of 7% in the group of 14 to 17 year olds. were reported, which corresponds to an incidence of 111 In adults, this percentage of Borrelia antibodies is even per 100,000 inhabitants [9]. In terms of early manifesta- higher. In the group of 70 to 79 year olds, 24.5% of men tions, a localised erythema migrans was diagnosed in and 16.4% of women are seropositive (Figure 1) [13]. 89% of the cases and a disseminated erythema migrans A prospective investigation of the incidence of Lyme bor- in a further 3% of cases. Borrelial lymphocytoma was reliosis in Finland and southern Sweden (2008–2009) established in 2% of cases, early-stage neuroborreliosis revealed that 78 (5%) of the 1,546 people bitten by a tick in 3%, and carditis in <1%. In terms of late-stage forms had a Borrelia burgdorferi infection. In 45 of the cases of the disease, Lyme arthritis appeared in 5% of patients (3%) only a seroconversion occurred; 33 (2%) resulted in and acrodermatitis chronica atrophicans in 1%. No illness. Erythema migrans was diagnosed in 28 people, chronic neuroborreliosis was detected. one person had borrelial lymphocytoma, two people had Currently nine states in Germany have an obligation to an acute case of neuroborreliosis and 2 had unspecified report acute manifestations of Lyme borreliosis (see An- symptoms which were diagnosed as Lyme borreliosis nex 4 in Attachment 1). Epidemiological data obtained [14]. through this partial obligation to report are only based on the clearly diagnosable manifestations, such as erythema migrans, acute neuroborreliosis and acute Lyme arthritis. Thus, it can be assumed that the rate of incidence is considerably underreported [10], [11]. Secondary data analyses of health insurance data based on the ICD 10 coding A 69.2 (G) result in much higher rates of incidence [12].

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4 Transmission routes 5 Pathogenesis

B. burgdorferi is transmitted to birds, mammals and hu- The pathogenesis of the borrelial infection is primarily mans from hard-bodied ticks of the I. ricinus/I. persul- determined by two factors: catus spp. complex during the blood meal. In Europe this 1. The evasion strategies of the pathogen [18], [19], transmission is primarily from I. ricinus, in Asia from [20]. I. persulcatus and in the USA predominantly from 2. The quality of the host’s immune response [21], [22], I. scapularis. Ticks suck blood in the course of their cycle [23], [24], [25], [26], [27], [28]. of development from larva to nymph to adult tick, and before they lay eggs. It is at this time that they can acquire Moreover, salivary proteins that are released in the course and/or transmit Borrelia. Small rodents – particularly of the tick’s blood meal also show immunosuppressive mice – and birds are the main reservoirs. Birds contribute effects [29], [30], [31], [32], [33], [34], [35], [36], [37]. to the geographical propagation of the infected ticks. In Host-specific inflammatory reactions in the skin also in- Germany, ticks are ubiquitously infected with Borrelia, fluence the course of the infection [38], [39]. however percentages can vary heavily from region to re- Some of the many strategies the Borrelia use to evade gion, even between areas very close in proximity (e.g. the host’s immune system include the ability to mask 4–21% [15]). their cell surface with proteins/inhibitors from the tick or The successful transmission from tick to mammal is the the host, and to modify their phenotype expression of cell result of a specific, highly complex vector-pathogen inter- surface proteins (outer surface protein: osp) according action. First the Borrelia are activated in the tick’s intes- to their environment [40], [41], [42], [43]. tines. Then they travel to the salivary glands where they Several Borrelia species form a resistance to complement- bind immunosuppressive salivary proteins to their surface mediated lysis by binding the regulators of the comple- [16]. Finally, they are secreted with the saliva in the bite ment cascade (factor H) to their surface [44], [45], [46], wound where they are at least partially protected from [47], [48]. By binding to plasminogens, Borrelia are cap- the host’s immune system by immunomodulating sub- able of breaking down collagen, fibronectin and laminin stances from the tick’s saliva which probably allows them [47], [49], [50], [51], [52] and disseminating in the skin. to reach a sufficiently high infection doses. A similar The innate immune system recognises the Borrelia mainly transmission through blood-sucking insects is therefore by their surface proteins (osp lipoproteins) [53], [54], close to impossible due to the short blood sucking time [55], [56], [57]. This interaction leads to the activation (lack of vector competence in insects for B. burgdorferi). of soluble factors, such as the complement system, as Xenobiotic tests reveal that it can take hours for the well as to the activation of target cells, like macrophages Borrelia to be transferred – depending on the species of and dendritic cells, and to the induction of inflammatory Borrelia [17]. cytokines [58], [59], [60], [61]. As the infection pro- When there is an occupationally higher risk of tick bites, gresses, specific immune responses are generated, par- cases of Lyme borreliosis (occupational disease No. 3102, ticularly the activation of T helper cells and B lymphocytes, diseases transmitted from animals to humans) should and the production of Borrelia-specific antibodies [20], be reported to the accident insurer by the attending [62], [63], [64]. In reservoir hosts, like wild mice, the an- physician or employer as a work-related illness as per Art. tibodies that form during an infection are able to prevent 202 of the Social Security Code VII (see Annex 4 in Attach- disease, however they are not able to eliminate the ment 1). pathogen. In contrast, the antibodies that form in patients are often unable to prevent the disease. However, antibodies against certain Borrelia antigens have also been shown to protect against subsequent infection in humans (see vaccines). There is no permanent immunity in humans after wild- type infection. Thus reinfection can occur.

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Table 1: Clinical manifestations of Lyme borreliosis

6 Clinical manifestations of Lyme 6.1 Localised cutaneous early-stage borreliosis infection Lyme borreliosis is an inflammatory multi-organ disease. 6.1.1 Erythema migrans It manifests itself initially as a localised infection of the skin called erythema migrans. Because of its light symp- The skin around the infectious tick bite can become infec- toms, this early-stage inflammation of the skin can be ted anywhere from 3 to 30 days after the tick bite occurs overlooked or not even be visible. The Borrelia can spread [67]. The extent and duration of the rash varies consider- haematogenically which is recognised clinically by flu-like ably between individuals. If the diameter of the erythema symptoms or disseminated erythemas of the skin. As the is more than 5 cm, a diagnosis of erythema migrans can disease progresses, manifestations can appear in other be made (Figure 2a and b) [68]. organs, with the nervous system and the joints primarily The clinical picture of a typical erythema migrans is a affected. The disease progresses very differently depend- marginated erythema that centrifugally spreads out ing on the individual. Therefore, it doesn’t make sense around the tick bite (Figure 2c and d). to classify the disease into stages. A distinction between early and late manifestations is preferable since the Features of a typical solitary erythema migrans clinical picture determines both the diagnosis and the treatment (Table 1). European studies show that Lyme • Free time interval between the tick bite and start of borreliosis manifests itself as a skin disease in 80–90% the erythema that is typically 3 days to several weeks. of patients and in other organs in around 10–20% of (Consensus: 18/20) patients [8], [9], [10], [14], [65], [66]. • Increasing centrifugal spreading of the erythema (crescendo reaction). (Consensus: 17/20) • Marginated, non-raised erythema that is at least 5 cm in diameter. (Strong consensus: 20/20) • A visible puncture site in the centre of the erythema. (Strong consensus: 20/20)

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Figure 2: Clinical variations of erythema migrans Fig. 2a: Initial seronegative erythema migrans 1 week after tick bite DD reaction to insect bite; diameter 4.9 cm, progression under observation Fig. 2b: Seronegative erythema migrans, elevation of IgM antibodies occured 5 days after start of treatment Fig. 2c: Typical marginated migrating erythema migrans Fig. 2d: Typical marginated erythema migrans with fresh areas of inflammation within the ring

6.1.2 Variability of the erythema migrans treatment the Borrelia can persist for months or years in (atypical erythema migrans) the skin and the erythema can slowly spread throughout the body. Often the red edge is the only evidence of the Very often the initial skin infection cannot be definitively inflammatory reaction to the migrating Borrelia. If the diagnosed clinically. Borrelia have been identified in ho- erythema migrans persists for multiple weeks and mogenously red and non-migrating erythemas, spotty and months, it is referred to as erythema chronicum migrans infiltrated erythemas (Figure 3b), erysipelas-like flaming ([66]: >4 weeks). In most cases (approx. 80%) serological red erythemas (Figure 3a) and in centrally vesicular detection of the IgG antibodies (sometimes even the IgM erythemas (Figure 3d) [69], [70]. The inflammation can antibodies) is possible [72]. completely disappear in the middle and fade to such as Erythema can disapear even without antibiotic treatment. extent that the erythema is only visible around the edges Spontaneous healing is possible, however the Borrelia – in the area of the migrating Borrelia – when heat is can persist even without a visible inflammatory reaction applied (Figure 3c). The erythema can also be haemor- and, after a period of latency, this can lead to further or- rhagic, particularly on the lower extremities (Figure 3e gan manifestations. and f). The centre can turn a dark purple colour (Figure 3f). The edge can be raised or urticarial. The former puncture site can be identified in the centre as a red papule (Figure 2a and b) [70], [71]. Without antibiotic

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Figure 3: Variability of the erythema migrans Fig. 3a: Flaming red erythema chronicum migrans with radiculitis on the left leg, DD erysipelas Fig. 3b: Blotchy purple erythema chronicum migrans on the upper thigh for 3 months Fig. 3c: Large light-red arch-shaped erythema chronicum migrans on the abdomen Fig. 3d: Centrally vesicular erythema migrans Fig. 3e: Haemorrhagic bullous erythema migrans on the foot Fig. 3f: Purple, haemorrhagic, non-migrating erythema chronicum migrans on the outer ankle with joint swelling

Variability of the erythema migrans (atypical erythema migrating erythema migrans (Figure 4b). Mostly it is soli- migrans) tary, in rare cases it is also disseminated. Borrelial lymphocytoma occurs more frequently in children than • Non-migrating in adults (7% in children and only 2% in adults with Lyme • Not marginated borreliosis, [8]). The favoured sites in children are the • Infiltrated instead of macular earlobes (Figure 4a and 4c), nipples and genital-anal area • Centrally vesicular (Figure 4f) [73]. The disease was first described as • Haemorrhagic lymphadenosis cutis benigna by Bäferstedt in 1944. • Irregular blotches B. burgdorferi s.l. can be detected in the pseudolympho- • Only visible when heat is applied to the skin mas [74]. Mostly it is a case of B. afzelii [75]. From a • No visible tick puncture site histological perspective, there are mixed B and T lymph- (Strong consensus 20/20) ocytic infiltrates. However purely B cell infiltrates can also Concluding recommendation: occur which are difficult to differentiate from low-grade Due to the extraordinary variability of the clinical B cell lymphoma (Figure 4d and e) [70]. Borrelial lymph- presentation, atypical erythema migrans is difficult for ocytoma can also occur in the late stages as part of an dermatologically inexperienced physicians to diagnose. acrodermatitis chronic atrophicans [73]. Therefore, patients with atypical erythema should be re- In the case of borrelial lymphocytoma, a substantial in- ferred to a dermatologist. (Strong consensus 19/20) crease in the number of IgG antibodies can be detected in the serum regardless of the length of infection [65], 6.1.3 Borrelial lymphocytoma [76]. In rare cases, multiple borrelial lymphocytomas can occur in the early disseminated stages or even in the late Pseudolymphoma (cutaneous lymphoid hyperplasia) can stages of the disease. In these cases, precise histological, occur in the early stages at the puncture site or in the immune-histochemical and molecular-genetic clarification

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Figure 4: Borrelial lymphocytoma Fig. 4a: Borrelial lymphocytoma preauricular and on the left earlobe Fig. 4b: Borrelial lymphocytoma on the right auricle near a non-marginated erythema migrans Fig. 4c: Pronounced nodular borrelial lymphocytoma on the earlobe Fig. 4d/e: Borrelial lymphocytoma on the sole of the foot with erythema migrans on the lower leg, histologically initially misdiagnosed as a low-grade malignant B cell lymphoma Fig. 4f: Small perineal borrelial lymphocytoma is required in order to diagnostically differentiate them multiple erythemata migrantia. This stage is very difficult from malignant cutaneous lymphomas. to diagnose if no erythemas are visible, or cannot be identified due to an atypical morphology. Significant features of borrelial lymphocytoma Multiple erythemata migrantia (MEM) • Pseudolymphoma, mostly solitary, more frequent in children The haematogenous dissemination of the Borrelia in the • Localised, above all on the earlobes, nipples or in the skin is noticeable by the many sharply marginated, genital area symptomless, oval erythemas of various sizes: multiple • Purple subcutaneous nodules or plaque erythemata migrantia (Figure 5b and 5c) [69], [77], [78]. • Histologically mostly mixed B and T lymphocytic infil- Children often experience symmetrical erythemas on their trates face, similar to fifth disease (parvovirus B 19 infection) (Strong consensus: 19/20) (Figure 5a) [68], [70]. MEM can be associated with systemic symptoms and acute neurological symptoms [79]. 6.2 Disseminated cutaneous early The histological picture is initially atypical. The typical manifestation perivascular plasma-cellular infiltrates are not found until the advanced stage of the disease. There is usually a Some of the patients experience haematogenous dissem- strong increase in IgM antibodies in the serum or the ination in the early stages of the disease which can be antibodies increase rapidly once treatment begins. There identified by flu-like symptoms such as a slight fever, is usually an increase in IgG antibodies. Borrelia taken arthralgia, myalgia, headaches, lymphadenopathy and

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Figure 5: Multiple erythemata migrantia (MEM) Fig. 5a and 5b: Pronounced erythemata migrantia on the right arm, approx. 40 more on the torso and lower extremities Fig. 5c: Oval erythema on the left cheek, many similar erythemas on the torso and upper leg a sign of early disseminated borreliosis Fig. 5d: Symmetrical redness on the cheeks of a 5-year-old girl with multiple erythemata migrantia on her trunk and extremities, accompanied by flu-like symptoms from skin lesions and, in rare cases, blood can be culti- ated cases have also been reported in children [82], [83], vated or their DNA can be detected using PCR [78], [80]. [84].

Significant features of multiple erythemata migrantia Oedematous infiltrative stage of ACA

• Symptomless, disseminated, round or oval redness Acrodermatitis initially manifests itself as pink reticular, on the skin (Strong consensus: 19/20) then increasingly purple, oedematous infiltrated cushion- • Without epidermal changes like erythemas, mostly on the extremities. The skin is in- • Ring-shaped or homogenous flamed, however there is initially no pain except for a • Often symmetrical erythemas on the face of children feeling of heaviness of the extremity. This is the oedemat- (similar to fifth disease) ous infiltrative stage of acrodermatitis chronica (Figure • Persisting over days or weeks 6a and 6b). These purple infiltrates can also appear on • Recurring at the same places the face and be confused with lupus erythematosus or a • Possible association with systemic or acute neuro- cutaneous malignant lymphoma [70]. logical symptoms (Strong consensus: 19/20) Atrophic stage of ACA

6.3 Cutaneous late manifestations In the course of the infection there is an increasing atrophy of all skin layers and skin appendages. Occasionally Acrodermatitis chronica atrophicans (ACA) juxta-articular rough fibroid nodules and band-shape stripes appear (Figure 6f), e.g. rare but typical inflamma- The disease can manifest itself in various organs after tory ulnar stripes and swelling in the heel and Achilles varying periods of time, from months to years depending tendon, or in other joints around the ACA (Figure 6b). This on the individual. A chronic skin infection mostly occurs results in circumscribed fibrosis or pseudo-scleroderma in older people and more frequently in women [81]. Isol- in the area of the ACA which can be confused with circumscribed scleroderma. Arthritides, arthralgia and myalgia

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Figure 6: Late cutaneous manifestations Fig. 6a–d: Oedematous infiltrative stage of acrodermatitis chronica Fig. 6a: Acrodermatitis chronica. Homogenous reddening of the left leg without atrophy, persisting for one year Fig. 6b: Acrodermatitis chronica in the oedematous infiltrative stage. Hard swelling and purple colouring of the right leg with swelling of the Achilles tendon and swelling of the ankle joint Fig. 6c: Acrodermatitis in the oedematous infiltrative stage. Blotchy purple confluent erythemas on the left arm of a 15-year-old girl Fig. 6d: Typical perivascular plasma-cellular infiltrate in the case of acrodermatitis chronica Fig. 6 e–g: Atrophic stage of ACA Fig. 6e: ACA – Purple colouring and atrophy on the back of the right hand and little finger, and purple blotches, stripes and infiltrates dorsally on the right knee Fig. 6f: ACA with ulnar stripes and purple blotches on the right underarm, and pronounced purple fibrous nodules below the elbow Fig. 6g: ACA with dark red to purple colouring and atrophy of the right hand dorsally (so-called “baked apple skin”) with swelling of the finger joints in the affected extremities are frequently associated with In the course of the infection, all of the affected skin be- ACA [81]. comes atrophic and there is a loss of body hair, connect- A peripheral neuropathy occurs in 40–60% of patients in ive tissue and fatty tissue (Figure 6e and 6g). When the association with ACA. It is characterized by a feeling of changes to the ACA-affected skin are symmetrical, they numbness, a tingling sensation, burning and an increased are difficult to differentiate clinically from age-related skin sensitivity to pain (allodynia) [85], [86], [87]. atrophy, acrocyanosis and chronic venous insufficiency. Without antibiotic treatment living Borrelia can be detect- From a histological standpoint, acrodermatitis chronica ed for years in the skin and in the fibroid nodules [88]. atrophicans is characterised by a pronounced perivascular

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plasma-cell rich inflammatory infiltrate in all layers of the Lyme arthritis can either be the initial symptom or it can skin (Figure 6d) and, in the late stage, by an increasing occur after a non-treated case of erythema migrans. atrophy of the epidermis, connective tissues and fatty Frequently the joint adjacent to the erythema migrans is tissues [89]. affected. This manifests itself as acute intermittent arth- An ACA diagnosis is based on a typical clinical presenta- ritis with voluminous, at times, painful joint swelling, tion, a typical histology and, as a rule, a high elevation of usually as mono or oligoarthritis. The knee joints are af- Borrelia IgG antibodies in the serum [81]. In unclear fected in 85% of the cases. The often massive swelling cases, particularly in the case of marginal elevation of of the knee leads, unusually frequently and early on, to antibody concentrations, the diagnosis has to be made the development of popliteal cysts (Baker’s cysts). Ankle by skin biopsy for histology and Borrelia DNA detection and elbow joints are less often affected, and almost by NAT (PCR), or if possible through the cultivation of never finger joints, especially in the form of a polyarthritis, Borrelia from the skin. have been observed. Lyme arthritis usually proceeds episodically, in other words, with repetitive inflammatory Significant clinical features of acrodermatitis chronica flare-ups that are interrupted by intervals of light to no atrophicans (ACA) symptoms. • Initial oedematous infiltrative stage (plasma-cellular 6.5 Differential diagnoses for cutaneous dermatitis) reddish colouring of the skin, mostly on one extremity Lyme borreliosis • Transition to the atrophic stage in the course of the disease, purple to brown colouring of the skin, skin The most frequent differential diagnoses for cutaneous atrophy, loss of body hair, connective and fatty tissues, Lyme borreliosis are listed in Table 2. emergence of veins, juxta-articular fibrous nodules The variety of differential diagnoses shows that, except and joint involvement for typical erythema migrans, most of the cutaneous • Association with a peripheral neuropathy in around manifestations of Lyme borreliosis require careful der- 50% of the cases matological diagnostic procedures. In particular, the lack • Older women more strongly affected (Strong con- of response to antibiotic treatment should not be uncrit- sensus: 19/19) ically interpreted as persistent borreliosis and treated for months with antibiotics. 6.4 Manifestations in the nervous It is, therefore, recommended to refer a patient with indis- tinct skin afflictions that persist after treatment to derma- system and joints associated with tologists or to dermatologically experienced paediatri- cutaneous borreliosis cians.

An acute neuroborreliosis can simultaneously appear as Recommendation: part of early-stage borreliosis with erythema migrans. Arnez et al. found pleocytosis in the cerebrospinal fluid • Skin inflammations that were diagnosed as Lyme of 26% of the 214 children diagnosed with multilocular borreliosis and which have not healed after lege artis erythemata migrantia. Of these, 11% had clinically antibiotic treatment shall be referred to a dermatolo- symptomatic lymphocytic meningitis [90]. Radiculoneur- gist. (Strong consensus 11/12) itis with characteristic nightly pain can also occur – in rare cases with paresis of the cranial nerves or peripheral nerves. A peripheral neuropathy of the affected extremity occurs in 50% of patients with ACA [87]. Rheumatic symptoms, above all myalgia and arthralgia, can occur in relatively early stages of the disease along- side erythema migrans. Cardiac symptoms with dys- rhythmia (AV block) should be watched for, which can occur during or after erythema migrans.

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Table 2: Clinical differential diagnoses of cutaneous Lyme borreliosis

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7 Diagnostics tion that is latent or cured, and after successful treatment. Thus, under certain circumstances, IgM reactivities or 7.1 Indirect pathogen detection specific IgG values after such infections can remain detectable for months or even years. Often low positive (serodiagnostics, detection of borrelial-specific antibody values are a sign of a previous antibodies) infection in the sense of persisting antibodies from a past infection (serological scar) [91]. However, a reinfec- Due to the complex characteristics of the pathogen, indir- tion cannot be excluded in the case of such a lab result. ect pathogen detection using serological methods con- Such findings have been detected in 20% of the people tinues to play a pivotal role in the diagnosis of Lyme bor- examined in serial investigations who belong to population reliosis in practical laboratory-based medical care. In ac- groups that are frequently exposed, e.g. forestry workers, cordance with the methods and standards required in without there being or having been any symptoms of ill- Germany, the antibodies are detected in a serum using ness [94], [95]. Possible coincidences of these types of a two tiered diagnostic approach with a standardised titres, with persisting antibodies from previous infections screening test (immunoassay: ELISA, CLIA etc.) and a and unspecified findings, are also possible amongst the confirmation assay (immunoblot). This is to ensure that normal population [13], [96] and can be responsible for the diagnostic procedure has a uniformly high level of erroneous interpretations and diagnoses. sensitivity and specificity (Table 3). Detection of elevated IgM antibodies only (without IgG) In Europe, diagnostics tests for borrelial serology do not effectively excludes a late manifestation of Lyme borrel- undergo any form of mandatory, extensive or independent iosis in the case of immune-competent patients. clinical evaluation as part of the approval process. Thus Diagnostic use of very sensitive early-phase antigens, a range of different test formats are on the market. In such as VlsE, which enable the detection of a specific IgG addition to various types of immunoassays, there are also response very early on in the course of the infection, a variety of test antigen preparations that use native and means specific IgM antibody findings as part of Lyme recombinant antigen combinations with, at times, differ- borreliosis diagnostics are playing an increasingly limited ent performance data. This partly explains the high degree role, especially since the IgM detection exhibits a poorer of variability in the lab results which depend on the overall specificity than the IgG detection [97], [98]. How- manufacturer and the test [12], [91]. Even though the ever positive IgG findings can persist, in part, in high principle testing procedures and the interpretation of concentrations over longer periods of time so that no serological test results are laid down as part of binding conclusions can be drawn regarding the activity of Lyme standards [92] in Germany, the interpretation of testing borreliosis or even the necessity for treatment in the ab- results, and in particular the evaluation criteria for im- sence of a classic activity marker, without additional munoblot testing, are subject to manufacturer-dependent clinical information and only on the basis of positive ser- differences and have to be done in accordance with the ological findings. At the same time, a statement can only respective manufacturer requirements as a result of the be made about the significance of changes in findings if variability and insufficient standardisation of commercial the comparison tests are carried out on serum samples test systems. This ongoing issue of insufficient testing that were taken at different times, ideally using a parallel standardisation is confirmed through meta-analytical in- approach as with the preserum, but, in any case, using vestigations as part of external quality controls [12], [93]. the same test [91], [99]. In this respect, attending physicians should be aware of An analysis using immunoblot within the framework of the qualifications of their diagnostic laboratory and the the stepwise diagnostic approach generally serves to not diagnostic assays and test specifications which it uses. only specifically confirm the findings of the screening test, it also enables the immune response to be divided into The course of the immune response and an early and late stage so that a better correlation can interpretation of the findings be made between the lab findings and the clinical symptoms based on the characteristic band spectrum, partic- In the course of a natural infection, specific IgM an- ularly in the IgG immunoblot. Thus a narrow spectrum of tibodies are usually detectable 3–6 weeks after the onset bands with antibodies against early-phase antigens (e.g. of the illness; IgG antibodies reach their peak more slowly VlsE, OspC, p41) is typically compatible with an early (weeks to months). manifestation (e.g. erythema migrans, facial paresis) or It should be further noted that, after early, successful a brief latent infection. However, it does not point to treatment of early manifestations, seroconversion can persistent clinical symptoms [91], [99], [100], [101]. In fail to appear under certain circumstances or, in the case contrast, a wide band spectrum, including reactions to of a positive detection of IgM antibodies, there doesn’t late-phase antigens (e.g. p100, p17/p18), fits in well have to be a regular continuation of the immune response with a late manifestation (e.g. arthritis, acrodermatitis) in the sense of a conversion from IgM to IgG. In contrast [100], [101], also with an asymptomatic persistence of to textbook examples of the courses of immune response antibodies (serological scar), however it primarily does for many viral diseases, the antibody response to Lyme not point to an early manifestation or a short course of borreliosis often regresses very slowly both after an infec- infection. Reinfections are difficult to detect based only

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Table 3: Two tiered serological diagnostic approach (as per MIQ 12 and DIN 58969-44 2005-07)

on serological test results without additional clinical in- Dissenting opinion (German Borreliosis Society) formation and can only be detected based on a clearly • There are no systematic studies on the frequency of verifiable IgG increase in a parallel approach, or signif- Bb antibodies in the case of late-stage Lyme borrelios- icant changes in the immunoblot band pattern in serum is. The view that an isolated IgM detection argues samples that are tested in parallel. against a late manifestation of Lyme borreliosis has One major premise of serological testing for Lyme bor- not been verified by the literature. reliosis is the fact that the referring physician needs to be aware that these types of tests should only be requested when there is reasonable clinical suspicion. 7.2 Direct pathogen detection Only when there is sufficiently high pre-test probability The respective microbiological diagnostic quality stand- (prevalence of Lyme borreliosis in the patient cohort being ards (MiQ Lyme borreliosis, MiQ PCR) apply in the direct investigated >20%) can a sufficiently utilisable positive pathogen detection of Lyme borreliosis using culture and predictive value of a positive test result even be assumed PCR. [102]. If the test is only ordered to exclude Lyme borreliosis in the case of unspecified or non-typical disease 7.2.1 Culture symptoms, the positive predictive value of the lab test drops to almost zero with respect to the possible confirm- Direct detection by culture with the modified Barbour- ation of Lyme borreliosis. On the other hand, due to the Stoenner-Kelly medium is considered to be the gold relatively low overall prevalence and incidence of Lyme standard and to be clear proof of an infection with borreliosis in the general public, a negative test result, B. burgdorferi [103], [104]. Direct detection of skin which excludes the disease in immune-competent pa- manifestations by culture are frequently successful. To tients with persisting symptoms, has an excellent negative a limited degree, detection by culture is also possible in predictive value. liquor and, in very rare cases, in synovial fluid, synovial biopsies and blood. In individual cases, the detection of Recommendation: B. burgdorferi has also been achieved in other tissue • Serological diagnostics shall only be ordered when samples, e.g. heart muscle and iris [105], [106]. Cultivat- there is sufficient clinical suspicion. (Strong consensus: ing from patient samples using suitable media is time- 19/19) consuming and materially intensive, and usually takes • The diagnostics shall be conducted using a stepwise more than two weeks. The sensitivity of the methods in approach (screening test and confirmation test). European studies is between 40% and 90% for erythema (Consensus: 16/19) migrans and between 20% and 60% for ACA [107], [108], • Positive antibody detection is not proof of a clinically [109], [110]. Overview in: [111]. Because of the invasive- present Lyme borreliosis. (Strong consensus: 19/19) ness of the sample taking, direct detection by culture • Negative antibody detection almost entirely excludes should therefore be based on a clear indication and expli- Lyme borreliosis in healthy immune system patients citly remain limited to specially identified reference with a protracted duration of illness. (Consensus: laboratories, such as the National Reference Centre for 16/19) Borrelia at the Bavarian State Office for Health and Food • An isolated positive IgM detection argues against a Safety in Oberschleissheim. In addition, further molecular- late manifestation of Lyme borreliosis. (Consensus: biological confirmation assays are required in positive 17/19) cases.

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Recommendations for direct detection by culture: • A positive PCR test result shall be confirmed by further molecular-biological methods and the detected geno- • Direct detection by culture should only be used in dif- species shall be indicated in the findings. (Strong ferential-diagnostically ambiguous cases. (Strong consensus: 19/19) consensus: 19/19) • A positive PCR test result after treatment with antibiot- • The cultivation of Borrelia burgdorferi sensu lato ics in accordance with the guidelines or without typical should be limited to specialist laboratories. (Strong clinical manifestation has no clinical relevance. (Con- consensus: 19/19) sensus: 16/19) • Positive culture results are to be confirmed using • Direct molecular-biological detection should be limited suitable molecular-biological methods. (Strong con- to ambiguous skin manifestations and reserved for sensus: 18/19) specially identified microbiological laboratories. (Strong 7.2.2 Direct detection using consensus: 20/20) molecular-biological detection methods 7.3 Diagnosis of clinical skin The detection methods currently being used in Lyme manifestations borreliosis diagnosis should be regarded as having a low level of standardisation [112]. This applies to DNA isola- 7.3.1 Erythema migrans (typical) tion from suitable clinical materials, as well as to the reaction conditions and the selection of the reaction starter If a clinically typical erythema migrans is present (see molecules (primers). In principle, the detection of Borrelia section on clinical manifestations) no further laboratory from a skin biopsy using nucleic acid amplification tech- diagnostic confirmation needs to occur; antibiotic treat- niques (NAT, usually PCR) is very reliable and, in the case ment should begin immediately (Figure 7). of early manifestations, is more sensitive than serological antibody detection. The diagnostic sensitivity of NAT is Recommendation: around 70% for detection from biopsies from erythema • If a typical erythema migrans is present (see section migrans and acrodermatitis chronica atrophicans [107], on clinical Manifestations) no further laboratory dia- [113], [114], [115], [116]. However, positive results have gnostic confirmation (serological, cultural, molecular- to be confirmed through molecular-biological confirmation biological) needs to occur. (Strong consensus: 20/20) assays with regard to specificity (probe hybridisation, se- • If a typical erythema migrans is present, antibiotic quencing of the amplificate) and the results must be in- treatment shall begin immediately. (Strong consensus: dicated in the findings. 20/20) After treatment, Borrelia DNA can still be detected for weeks – or even months – in the affected area of skin 7.3.2 Erythema migrans (atypical) before conclusions can be drawn as to whether the therapy has failed [117], [118], [119]. Molecular-biological If an atypical erythema migrans is suspected, antibody detection of pathogens without the simultaneous pres- and pathogen detection by PCR and culture is available. ence of typical disease manifestions is not clinically rel- A serological test should be carried out in every case. If evant. Direct molecular-biological detection from urine the findings remain ambiguous, the aim should be samples is not currently recommended due to ambiguous pathogen detection using PCR, if necessary also by culture diagnostic sensitivity and specificity [113], [120], [121]. (Figure 7). A skin biopsy should be taken near the in- Because of the invasiveness of the sample taking, direct flamed edge. After informing the patient and obtaining detection by culture should therefore be based on a clear written consent, the selected area of the skin is numbed indication (e.g. unexplained skin manifestation that has using local anaesthesia. After thorough disinfection of been differentially diagnosed) and explicitly remain limited the skin, a 4 mm punch is used to remove the skin, which to specially identified reference laboratories, such as the is put in a sterile vessel with 0.9% saline solution. Direct National Reference Centre for Borrelia at the Bavarian inoculation in the cultivation medium only makes sense State Office for Health and Food Safety in Oberschleiss- when the sample can be processed in the lab within a heim. In addition, further molecular-biological confirma- few hours. Otherwise, fast growing skin bacteria can tion assays are required in positive cases. hamper the cultivation of the Borrelia. A histological analysis rarely has a guiding nature in the Recommendations for direct molecular-biological detec- case of erythema migrans. It can, however, make sense tion: for differential-diagnostic clarification. • Direct molecular-biological detection (PCR) is not a screening test if there is suspicion of Lyme borreliosis. Recommendation: (Strong consensus: 19/19) • In the case of an atypical clinical appearance of • A negative PCR test result does not exclude Lyme erythema migrans, suspicion shall be clarified through borreliosis. (Strong consensus: 19/19) a serological test. (Consensus: 18/20)

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Figure 7: Algorithm for diagnosing a solitary or multilocular erythema migrans

• If the serological test is negative and the clinical sus- PCR and culture allow B. burgdorferi to be detected. Al- picion remains, direct cultural or molecular-biological though there is limited data on the sensitivity of the detection from biopsy material shall be used for clari- methods used to identify borrelial lymphocytoma; a PCR fication. (Strong consensus: 20/20) detection success rate can be expected in around 70% of the cases [73], [122]. 7.3.3 Multiple erythemata migrantia (MEM) Recommendation: If multiple erythemata migrantia, also known as multilocular erythema migrans (MEM) is suspected, serological • If there is an unambiguous clinical presentation of antibody detection and pathogen detection using PCR borrelial lymphocytoma and a positive serology, further and culture from a skin biopsy are available. A serological microbiological tests are not required. (Strong con- test should be carried out in every case. If the findings sensus: 20/20) remain ambiguous, the aim should be to detect the • If there is an unambiguous clinical presentation of pathogen using PCR, if necessary also by culture borrelial lymphocytoma, antibiotic treatment shall be- (Figure 7) (see 7.2.1). Clinical signs of extra-cutaneous gin immediately. (Consensus 16/20) symptoms should be watched for in the case of MEM (see • If the clinical presentation is not unambiguous and the Table 1 in the section on clinical manifestations). serology is negative, further tests (primarily histology, molecular-biology, possibly culture) shall be conducted Recommendations: for differential-diagnostic clarification. (Strong consensus 20/20) • A serological test shall be carried out when MEM is suspected. (Strong consensus : 20/20) 7.3.5 Acrodermatitis chronica atrophicans • If the serological test is negative and the clinical suspicion remains, direct cultural or molecular-biological If ACA is clinically suspected, a Borrelia serology should detection in biopsy material shall be used for clarifica- be carried out first. High antibody values in the IgG tion. (Strong consensus: 20/20) screening test, combined with a broad spectrum of borrelial-specific bands in the IgG blot or similar tests (see 7.3.4 Borrelial lymphocytoma Section 7.1), are indications of ACA. A negative IgG serology excludes, with high certainty, ACA in immune-compet- Confirming the diagnosis through serological antibody ent patients. detection is obligatory and, in most cases, antibodies In ambiguous cases the patient should be referred to a against B. burgdorferi can be detected [38], [70], [122]. dermatologist for differential diagnosis. If uncertainty re- When the findings are still ambiguous, the patient shall mains, two skin biopsies (see 7.2.2.) should be taken be referred to a dermatologist in order to detect the from the abnormal patch of skin: one for the histological pathogen by PCR or, if necessary, culture. Two skin test in a 4% formalin solution, and one for the culture biopsies should be taken from the abnormal skin (see and PCR test in physiological saline solution. In the case 7.2.2): one for the histological test in a 4% formalin of ACA, B. burgdorferi DNA can be detected in around solution, and one for the culture and PCR test in sterile, 70% of the cases. physiological saline solution.

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Table 4: Interpretation of serological result constellations

Recommendation: detection using culture and molecular-biological methods. (Strong consensus: 20/20) • When ACA is clinically suspected, the diagnosis shall be confirmed through a serological test. (Strong consensus: 19/20) 7.4 Non-recommended diagnostic • High IgG antibody values in the screening test, com- approaches bined with a broad band pattern in the IgG immunoblot test, indicate a suspected clinical diagnosis. (Strong In addition to the traditional diagnostic methods listed consensus: 20/20) above, which are used when Lyme borreliosis is suspect- • A negative Borrelia serology excludes ACA with a high ed, the literature describes a whole series of diagnostic degree of certainty in immune-competent patients. techniques that, in part, have been inconclusively evalu- (Strong consensus: 20/20) ated. This includes the immuno-histochemical detection • The diagnosis shall be histologically confirmed in all of B. burgdorferi in biopsies and of antigens from blood cases. (Majority approval: 12/20) and urine, as well as functional tests that test for cellular • When the clinical picture is ambiguous, further dia- immunity (lymphocyte transformation tests (LTT), cytokine gnostic clarification through biopsy and subsequent detection). Currently there is a lack of scientific investiga- histological testing should be done. When the findings tions that prove there is a diagnostic benefit. Because are unclear, direct detection by culture and molecular the available LTT methods lack specificity, they should biology is recommended. (Strong consensus: 19/20) not be used.

7.3.6 Ambiguous dermatological pathologies Methods that are not recommended for use in the dia- with a suspicion of Lyme borreliosis gnosis of cutaneous manifestations of Lyme borreliosis: • Immunohistochemical detection of Borrelia from tissue See Table 4. is currently not recommended. (Strong consensus: 19/19) Recommendation: • The lymphocyte transformation test (LTT) and the de- • If a cutaneous manifestation of Lyme borreliosis is tection of specific cytokines is currently not recom- suspected and there is no unambiguous clinical mended. (Strong consensus: 18/19) presentation, a skin biopsy with a histological examin- • Detection of Borrelia in engorged ticks is not recom- ation shall be conducted along with direct pathogen mended. (Strong consensus: 19/19)

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• Detection of Borrelia antigens from patient samples 8 Treatment of cutaneous Lyme is currently not recommended. (Strong consensus: 19/19) borreliosis • Direct detection of Borrelia in patient samples using Recommendations for treating Lyme borreliosis have light microscopy is currently not recommended. (Strong been published in numerous European and American consensus: 18/19) guidelines since 2004 (see Annex 2 “Comparison of • The detection of circulating immune complexes is Guidelines and Therapies” in Attachment 1). currently not recommended. (Strong consensus: Table 5 summarises the best-evaluated antibiotic ther- 18/19) apies taken from American and European guidelines. Doxycycline and amoxicillin are the antibiotics of choice 7.5 Quality control and quality assurance in all guidelines. Both antibiotics are very effective in the dosages listed According to the guidelines of the German Medical Asso- in Table 5 and are usually tolerated well. Gastrointestinal ciation (Bundesärztekammer), diagnostic laboratories complaints can occur during treatment with doxycycline. must currently participate in infection-related serological It is particularly important that they are not taken together round robin tests twice a year. This applies to serological with dairy products. Furthermore, patients should be in- antibody detection and to direct molecular-biological de- formed of the risk of phototoxic skin reactions and use tection of Borrelia when Lyme borreliosis is suspected. light stabilisers when taking the antibiotics. The results of the external quality assessment tests (EQA During treatment with amoxicillin, non-allergenic skin tests), which INSTAND e.V. has been carrying out for th exanthemas frequently appear on the 8 day on the torso. years, reveal extensive heterogeneity in the testing sys- If they are light exanthemas, the treatment can continue. tems currently on the market. The pass rates for the If itching occurs, symptoms can be treated with antihistam- conventional serological and molecular-biological test ines and skin care products. Corticosteroids are not ne- systems, which have been collected from meta-analytical cessary. data, show that, despite good analytical pass rates for Of the oral cephalosporins, only cefuroxime axetile has immunoassays and molecular-biological tests, clinical demonstrated an efficacy that is comparable to treatment diagnostic interpretation of the result constellations often with doxycycline and amoxicillin [123]. The absolute proves difficult and can hamper medical treatment in bioavailability of cefuroxime axetil is comparatively low daily clinical practice [12], [91]. Thus, when Lyme borrel- (40–45%). The best resorption is achieved when it is iosis is suspected, infection diagnostics are to be conduct- taken directly after a meal. ed in laboratories that meet the laboratory diagnostic st nd Other 1 and 2 generation cephalosporins are not effect- standards in accordance with the diagnostic guidelines ive enough [124]. of the expert medical societies and the guidelines of the In the case of disseminated early-stage infection, intra- German Medical Association. These laboratories must venous treatment with ceftriaxone does not achieve any regularly and successfully participate in external quality better results than oral doxycycline treatment [125]. assurance tests (round robin tests). Physicians treating Of the macrolides, azithromycin has proven to be ad- patients with Lyme borreliosis should query about and equately effective [79], [126], [127], [128]. The long tis- ensure that these prerequisites are met in the laborator- sue half-life period is advantageous because of the long ies charged with carrying out their diagnostic testing. If generation time of Borrelia. The efficacy of clarithromycin questionable result constellations or implausible test is regarded as controversial. Clarithromycin was compared results are produced, expert laboratories specialising in with amoxicillin in one of the newer, open, randomised Lyme borreliosis diagnostics and the National Reference comparative studies of children with erythema migrans Centre for Borreliosis at the Bavarian State Office for and was classified as equally effective [129]. Roxithromy- Health and Food Safety in Oberschleissheim should be cin is not effective enough. Because of its uncertain re- consulted. sorption and indications of resistance, erythromycin is no longer a treatment of choice [28], [130]. Recommendation: Treatment with oral penicillin V is controversial. Austrian, • Attending physicians shall be aware of whether their Swedish and Slovenian studies show that it is sufficiently diagnostic laboratory complies with the respective effective [90], [131], [132], [133]. diagnostic standards and qualifications and the extent It is particularly important that dosage and length of to which the diagnostic assays used there conform to treatment are observed. guidelines. (Strong consensus: 18/19) Cutaneous early manifestations should be treated for 10–21 days (Table 5). The length of treatment depends on the duration and severity of the clinical symptoms; in the case of solitary erythema migrans without general symptoms, a 10 to 14 day treatment is sufficient. In a comparative study by Stupica et al. [134] the results of treating localised erythema migrans with doxycycline for

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Table 5: Treatment recommendations for cutaneous Lyme borreliosis

10 versus 14 days were evaluated. There were no differ- cephalosporins ceftriaxone or cefotaxime may be neces- ences in the way the erythema healed. In both treatment sary. groups symptoms persisted no longer or more frequently The cure rates – defined as the reinstatement of the than in healthy subjects. Treatment should last 21 days body’s original condition with regression of the disease- if there is evidence that the Borrelia has disseminated specific symptoms after successful treatment – is (indicated by a flu-like feeling), or in the case of multiple between 95%–100% when the localised and dissemin- erythemata migrantia and borrelial lymphocytoma. ated early manifestations are treated in time [136], [137]. Taking doxycycline or amoxicillin orally for 30 days to treat Treatment failure with evidence of the pathogens after cutaneous late manifestations (acrodermatitis chronica therapy rarely occurs if the treatment is conducted lege in the oedematous-infiltrative or atrophic stage) without artis [45], [138]; individual cases have been published neurological involvement is usually sufficient [81], [135]. [104], [105], [139], [140], [141], [142]. However, if there are also neurological symptoms, intra- Two larger studies were able to show that new infections venous treatment with penicillin G or 3rd generation with other Borrelia strains were the reason why Lyme borreliosis returned in every case [143], [144].

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Currently there are no indications of a development of 8.2 Treatment of children secondary antibiotic resistance of B. burgdorferi to the antibiotics recommended in the guidelines [145], [146], Children can be treated with 4 mg/kg KG/day (up to a [147], [148]. maximum dosage of 200 mg/day) of doxycycline once If the late manifestations remain untreated for a long their tooth enamel has completely formed at age 9 and period of time, there is a higher risk of the patient having over (>8 years). For children under 8, the treatment of persistent physical symptoms and of their skin, joints and choice is 50 mg/kg KG/day of amoxicillin (Table 5). nervous system not properly healing. Taking it the required 3 times a day can be difficult for It is disputed whether repeated antibiotic treatment kindergarten- and school-aged children. makes sense for these patients with persisting com- Alternatively, cefuroxime axetil 30 mg/kg KG/day, azith- plaints. According to published randomised controlled romycin 5–10 mg/kg KG/day or clarithromycin 15 mg/kg trials (RCT), long-term antibiotic treatment is less than KG/day can be prescribed, which is taken twice daily promising [149], [150], [151], [152], [153], [154]. [129]. A European RCT published in 2016 (PLEASE Study) looked at 280 patients whose complaints persisted for more 8.3 Therapy adherence than 2 years after their Lyme borreliosis had been treated with antibiotics (78 patients after erythema migrans, In order to improve treatment adherence/therapy com- 15 patients after meningoradiculitis) and 153 seropositive pliance, the patient should be informed before beginning patients with borreliosis-related complaints after a tick the treatment of the aspects of taking prescribed antibi- bite. The study compared the health-related effects of a otics and the potential risks of undesired effects. 2-week compared to a 14-week round of antibiotics. First, A frequent cause of treatment failure is the incorrect ad- all of the patients that had previously been treated with ministration of doxycycline. It should be noted that resorp- antibiotics were given 2 g of ceftriaxone i.v. for 2 weeks. tion can be compromised when it is taken together with Then the patients were randomly placed in 3 groups. bivalent or trivalent cations, such as aluminium, calcium Group 1 received doxycycline 200 mg/d p.o. for 12 weeks, (milk, dairy products and fruit juice containing calcium), Group 2 clarithromycin 2x 500 mg plus hydroxychloroquin and magnesium, in antacids or through iron supplements, 2x 200 mg/d for 12 weeks, and Group 3 a placebo for as well as through activated charcoal and colestyramine. 12 weeks. Treatment success was assessed as health- Therefore, there should be a 2 to 3 hour time span based quality of life after 14 weeks and then up to 52 between when the antibiotic is taken and the medicine weeks using the RAND 36 Health Status Inventory. The or food is ingested. aggregate score improved equally after treatment in all Another reason for treatment failure is irregular adminis- three groups without a significant difference. The assess- tration e.g. forgetting to take the midday dose in the case ment of the quality of life remained lower than in the of amoxicillin, or when the length of antibiotic treatment general population in all three groups. No difference in is insufficient e.g. due to a deterioration in symptoms as treatment success between the short-term treatment and a result of a Herxheimer reaction, because of gastrointest- the two long-term treatments could be made. Patients inal complaints, or as a result of phototoxic skin reactions receiving the long-term treatment had considerably more through increased sensitivity to light from doxycycline. antibiotic-related side-effects (primarily photosensitivity In the case of a disseminated infection, the patient should (18.6%) and nausea (10.5%) in connection with doxycyc- be informed about a possible Herxheimer reaction with line, and primarily nausea (10.4%), diarrhoea (9.4%) and a flare up of the erythemas, which occurs in approx. 10% allergic exanthemas (8.3%) in connection with clarithro- of cases, a feeling of being very unwell, and a rise in mycin/hydroxychloroquine.) Vision problems were the temperature in approx. 2% of cases within 24 hours of most frequent complaint of the placebo group (10% of taking the antibiotics [78], [129]. Occasionally this reac- the patients) [155], [156]. tion is delayed. It is a temporary immunological reaction as a result of the upregulation of proinflammatory cy- 8.1 Treatment during pregnancy and tokines and can be treated, for example, with non-steroid- nursing al anti-inflammatory drugs (NSAID). Cortisone treatment is not necessary. The antibiotic should continue to be Oral treatment with amoxicillin p.o. is recommended taken. during pregnancy and nursing. Alternatively, penicillin G and ceftriaxone can be administered i.v. [157], [158]. If Recommendations for treating cutaneous Lyme borreli- the patient has an identified allergy to penicillin, azithro- osis: mycin or cefuroxime axetil can be prescribed after strong indication. Ceftriaxone can be taken intravenously under Antibiotics clinical surveillance since the risk of a cross allergy between penicillin and 3rd generation cephalosporins is • Doxycycline or amoxicillin p.o. are the treatments of around 1% [159]. choice (Strong consensus: 17/18)

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• Treatment alternatives are cefuroxime, azithromycin, Dissenting opinion (OnLyme Aktion) possibly also clarithromycin p.o. (Strong consensus: • When other causal factors can be excluded and cu- 17/18) taneous, illness-specific symptoms recur or do not re- • Ceftriaxone i.v. is the treatment of choice for cutaneous gress, another suitable antibiotic can be considered, Lyme borreliosis with neurological manifestations taking into account the patient’s individual situation. (Majority approval: 10/19) • See the recommendations of other expert medical Dissenting opinion (German Borreliosis Society) societies for antibiotic treatment of patients with cu- • There are no evidence-based studies on the efficacy taneous Lyme borreliosis with neurological or cardiolo- of treating late-stage Lyme borreliosis, particularly ACA, gical manifestations. Possibilities include ceftriaxone with antibiotics. The paper by Aberer et al. (1996) i.v., cefotaxime i.v., penicillin G i.v. or doxycycline p.o. [135], cited in the text, states that the efficacy of (Strong consensus: 18/18) ceftriaxone needs to be reviewed in further studies. In Duration of treatment terms of oral antibiotics, it has been established that the length of treatment is a more critical factor than • The treatment of the early manifestations of cutaneous the type of antibiotic (penicillin/doxycycline). Lyme borreliosis shall last 14–21 days. (Exceptions are azithromycin 5–10 days; doxycycline 10–14 days in the case of solitary erythema migrans) (Consensus: 8.4 Persisting symptoms after 17/19) treatment/post-treatment Lyme disease • The treatment of cutaneous late manifestations shall syndrome (PTLS) last 30 days. (Consensus: 17/19) • A general extension of treatment beyond the recom- After antibiotic treatment has been carried out in accord- mended amount of time is not recommended. (Con- ance with the guidelines, inflammatory reactions can sensus: 17/19) persist and symptoms such as tiredness, joint and muscle • Treatment can be extended in individual cases depend- pain, headaches, a general feeling of being unwell, irritab- ing on the clinical progression and after a re-evaluation ility or paraesthesia can last for months. If the unspecific of the diagnosis. (Consensus: 17/19) constitutional symptoms last for more than 6 months, it • Treatment is renewed on a case-by-case basis when is considered by some authors to be post-Lyme syndrome the pathogen has been confirmed. (Consensus: 16/19) (PLS) or post-treatment Lyme disease syndrome (PTLDS) • The diagnosis should be re-evaluated if the cutaneous [150], [160]. So-called PTLDS is a syndrome that has yet symptoms persist or progress despite treatment with to be generally defined scientifically and therefore is not antibiotics in line with the guidelines. (Consensus: yet universally accepted. It can be diagnostically differen- 17/19) tiated from diagnosed late manifestations of Lyme dis- Recommendations for treating cutaneous Lyme borreli- ease and symptoms resulting from persisting reproducible osis during pregnancy: pathogens and from improper healing. The benefit of repeated and long-term treatment with antibiotics has not • Amoxicillin p.o. shall be administered as the treatment been verified. of choice during pregnancy. (Strong consensus: 18/18) In a controlled study of patients with erythema migrans, • Penicillin G i.v. and ceftriaxone i.v. represent alternative in which a control group containing individuals of similar therapies during pregnancy. (Strong consensus: age and gender was simultaneously studied, no increased 18/18) incidence of post-therapeutic symptoms compared to the • If the patient is allergic to penicillin, cefuroxime p.o., control group were identified [136]. ceftriaxone i.v., cefotaxime i.v. or azithromycin p.o. Several studies indicate special immunological character- should be used. (Consensus: 15/17) istics. Patients who have persisting symptoms for months Recommendations for treating cutaneous Lyme borreli- to years after receiving antibiotic treatment were identi- osis in children: fied as frequently having anti-neural antibodies [161], as well as a weaker Th1-immune response with elevated • Amoxicillin p.o. shall be administered as the treatment interleukin 23 concentrations in serum [39]. of choice in children under 8. (Strong consensus: Bockenstedt et al. were able to identify Borrelia DNA in 17/17) mice when treatment was focussed near cartilage, how- • Children aged 9 and over can take doxycycline p.o. ever they did not find any living Borrelia [117]. Persisting (Strong consensus: 17/17) DNA and RNA, as well as living Borrelia, were detected • Azithromycin, clarithromycin or cefuroxime p.o. repres- in rhesus monkeys through xenodiagnoses (transfer of ent alternative treatments for children (Strong con- tissue to laboratory animals) [162]. Since these were sensus: 17/17) animal studies, no statement on what this means for human infections can currently be made.

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8.5 Course of action for persisting skin the patient shall be referred to a dermatologist for a differential diagnosis of circumscribed scleroderma changes and symptoms after antibiotic (morphea), granuloma annulare, sarcoidosis, erythema treatment annulare et diutinum, tinea or urticarial vasculitis. (Strong consensus: 17/17) A primary incorrect diagnosis is a common reason for • If a lymphocytoma persists or progresses after treat- persisting skin changes and symptoms after treatment ment the patient shall be referred to a dermatologist with antibiotics [163]. for a differential diagnosis (cutaneous pseudolymph- In the case of clinically diagnosed erythema migrans and oma, Jessner’s lymphocytic infiltration or malignant multiple erythemata migrantia that do not heal within lymphoma). (Strong consensus: 17/17) 6 weeks, a differential diagnosis of circumscribed • If the acrodermatitis chronica atrophicans persists scleroderma (morphea), granuloma annulare, sarcoidosis, after treatment the patient shall be referred to a der- erythema annulare et diutinum, tinea (with low epidermal matologist for further consultation and for a differential involvement) or uticarial vasculitis should be considered. diagnosis (age-related skin atrophy, chronic thermal Patients should be referred to a dermatologist for further damage to the skin e.g. chilblains and heat melanosis, diagnostics. Borrelial lymphocytoma often heals very chronic venous insufficiency with stasis dermatitis). slowly over many months. According to studies by (Strong consensus: 16/16) Maraspin et al. on 85 patients, healing time was, on av- erage, 28 days (7–270 days). The longer the borrelial lymphocytoma was present, the longer it took to heal 9 Prophylaxis [73]. If the knots persist for more than one year, or new knots appear, a skin biopsy should be carried out by a 9.1 Preventing tick bites dermatologist for a histological diagnosis and Borrelia PCR. Cutaneous pseudolymphoma, Jessner’s lymphocytic The best prophylaxis is to prevent tick bites by wearing infiltration or a malignant lymphoma should be considered clothing that covers the body, and carefully checking the in the differential diagnosis. skin, including the scalp, after being outdoors. This is It takes years following antibiotic treatment for skin particularly important for children, who have an increased changes to slowly regress in the case of an acrodermatitis risk when playing outdoors between spring and autumn. chronica atrophicans that has persisted for years. The Insect repellents that are effective against ticks, e.g. di- atrophy of the skin, tissue and fat can be irreversible – ethyltoluamide (DEET), icaridin (1-(1-methylpropyl car- especially in older people. This also applies to ACA-asso- bonyl)-2-(2-hydroxyethyl)piperidine), ethyl butylacetylamino- ciated peripheral neuropathy. (See also the AWMF-S3 propionate (EBAAP, IR 3535) can also be used, however Guideline on Neuroborreliosis which is in progress.) their effectiveness is limited to up to 4 hours [164], [165]. Age-related skin atrophy, chronic thermal damage to the skin, e.g. chilblains and heat melanosis, as well as 9.2 Preventing Lyme borreliosis chronic venous insufficiency with stasis dermatitis can be considered in the differential diagnosis. Removing the ticks before they become engorged with Chronic neuropathic pain after adequate antibiotic blood is very important. The risk of a Borrelia transfer in- treatment of acrodermatitis chronica atrophicans with creases with the length of time that the tick sucks [17]. peripheral neuropathy is treated in accordance with the Transmission within the first 12 hours has rarely been DGN’s guideline “Neuropathic Pain” (AWMF – guidelines observed in laboratory animals. After being in a garden, register no. 030/114). park, field forest or meadow where there may have been All patients whose symptoms persist after antibiotic contact with a tick, the body should be checked the same treatment of cutaneous Lyme borreliosis should undergo evening for ticks. careful differential diagnostic clarification by respective The ticks should be removed immediately with a tick specialists, above all, for internal medicine (infectiology, tweezer or a tick card in order to prevent the transfer of rheumatology, cardiology, endocrinology), psychosomat- the Borrelia. If parts of the suction organ remain in the ics, psychotherapy, psychiatry or palliative care, since skin, they can later be removed with a needle or a curet- chronic infections with another etiology, other internal tage [160]. If the head or the suction organ remains in medical disorders, autoimmune diseases, chronic pain the skin, this is not critical in terms of a Borrelia transfer. syndrome, and depressive and somatoform disorders When nymphs and adult ticks are engorged with blood, should also be considered in the differential diagnosis their bodies should not be squeezed in order to prevent and need to be treated accordingly. a possible transfer of the Borrelia. Checking the tick that has been removed from the skin Recommendations for persisting symptoms after treat- for borrelia does not make sense since the detection of ment in accordance with the guidelines: the borrelia in the tick is not sufficiently predictive for whether the Borrelia has been transferred to the host • If an erythema or multiple erythemas persist after and for the emergence of the disease. treatment of erythema migrans (longer than 6 weeks),

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After removing the tick, the patient should be informed 9.4 Vaccines of the necessity of observing the bite site over the subsequent 6 weeks (Annex 1: “Patient information after a No approved vaccine that can be used on humans is tick bite” in Attachment 1). currently available. A vaccination with recombinant lipidated Osp A has been 9.3 Prophylactic treatment after a tick evaluated in the USA as part of a major study and has bite shown to be effective [171], [172]. The vaccine has been approved in the USA since 1999; however, it was taken According to an American study, the risk of infection after from the market by its manufacturer. The reason for this a tick bite can be reduced through a one-time prophylactic is not medical. Reports on undesired vaccine reactions administration of 200 mg of doxycycline (87% effective- in individuals who are genetically predispositioned were ness) [166], [167]. The results, however, should be inter- refuted by multiple qualified studies [173], [174], [175]. preted with caution since only one follow-up check took This monovalent vaccine is not suitable for Europe as it place after 6 weeks. Thus no statement can currently be only protects against an infection with B. burgdorferi made as to whether this is sufficiently effective with re- sensu stricto, and not against the genospecies B. afzelii gard to a late infection. and B. garinii that are frequently found in Europe. In light of the low risk of infection, doxycycline would have A polyvalent Osp A vaccine is currently being developed to be administered unnecessarily many times in order to for Europe [176], however approval is not expected in prevent a potential infection. According to projections of the foreseeable future. infection risk in endemic areas, 40–125 prophylaxes would have to be taken in order to prevent 1 infection [168]. Impact on the intestinal flora and a possible devel- Notes opment of resistance through frequent prophylaxis is conceivable. Therefore, oral doxycycline prophylaxis in Procedure for forming a consensus Europe is not recommended. The prophylactic application of an antibiotic cream is also The guideline was created using a modified Delphi pro- controversial. Animal studies with azithromycin cream cess and was voted on in an extended consensus confer- reveal a good prophylactic efficacy [169], [170]. Placebo- ence of the Interdisciplinary S3 Guideline Group, moder- controlled studies on the effectiveness in humans have ated by Prof. Ina Kopp, Head of the AWMF Institute for yet to be published. This treatment is not currently recom- Medical Knowledge Management. mended due to the lack of clinical data. It was passed by the 22 expert medical societies and patient organisations involved. Recommendations on infection prophylaxis: The guideline is a part of the registered Interdisciplinary S3 Overall Guideline on the “Diagnosis and Treatment of • Clothing that covers the body should be worn to pre- Lyme Borreliosis”. vent tick bites. • Using tick repellents can be recommended with some Support reservations. • Skin should be inspected in the evening for ticks after This guideline was created without the influence or finan- being outside in an area where there is a possibility of cial support of sponsors. the individual coming into contact with ticks. The funds required to create and to translate this • Ticks should be removed early in order to prevent Lyme guideline were provided by the German Society for Der- disease. matology and the Society for Promotion of Quality Assur- • The site of the bite should be observed for up to six ance in Medical Laboratories (INSTAND e. V.). weeks. Travel expenses were provided by the respective expert (Consensus: 15/16) medical societies. Not recommended: Declaration of competing interests by • Analysing the removed tick for Borrelia is not recommended. (Consensus: 15/16) the authors • Local or systemic prophylactic antibiotic treatment after a tick bite is not recommended. (Consensus: Table in the Guideline Report, Section 5 (in German): 14/16) http://www.awmf.org/uploads/tx_szleitlinien/013-044m_ S2k_Kutane_Lyme_Borreliose_2016-05_01.pdf.

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